Validity and Reliability of the Japanese Version of the
painDETECT Questionnaire: A Multicenter Observational
Study
Yoshitaka Matsubayashi1*, Katsushi Takeshita1, Masahiko Sumitani2, Yasushi Oshima1, Juichi Tonosu1,
So Kato1, Junichi Ohya1, Takeshi Oichi1, Naoki Okamoto1, Sakae Tanaka1
1 Department of Orthopaedic Surgery, Faculty of Medicine, the University of Tokyo, Tokyo, Japan, 2 Department of Anesthesiology and Pain Relief Center, the
University of Tokyo, Tokyo, Japan
Abstract
Objectives: The aim of this study was to evaluate the validity and reliability of the Japanese version of the
painDETECT questionnaire (PDQ-J).
Materials and Methods: The translation of the original PDQ into Japanese was achieved according to the published
guidelines. Subsequently, a multicenter observational study was performed to evaluate the validity and reliability of
PDQ-J, including 113 Japanese patients suffering from pain.
Results: Factor analysis revealed that the main component of PDQ-J comprises two determinative factors, which
account for 62% of the variance observed. Moreover, PDQ-J revealed statistically significant correlation with the
intensity of pain (Numerical Rating Scale), Physical Component Score, and Mental Component Score of the Medical
Outcomes Study 36-Item Short-Form Health Survey (SF-36). The Cronbach alpha for the total score was 0.78 and
for the main component was 0.80. In the analysis of test–retest method, the intraclass correlation coefficient between
the two scores was 0.94.
Conclusions: We demonstrated the validity and reliability of PDQ-J. We encourage researchers and clinicians to
use this tool for the assessment of patients who suffer suspected neuropathic pain.
Citation: Matsubayashi Y, Takeshita K, Sumitani M, Oshima Y, Tonosu J, et al. (2013) Validity and Reliability of the Japanese Version of the painDETECT
Questionnaire: A Multicenter Observational Study. PLoS ONE 8(9): e68013. doi:10.1371/journal.pone.0068013
Editor: Kazutaka Ikeda, Tokyo Metropolitan Institute of Medical Science, Japan
Received April 8, 2013; Accepted May 24, 2013; Published September 30, 2013
Copyright: © 2013 Matsubayashi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study received financial funds from the “Health and Labour Sciences Research Grant.” The funder had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
* E-mail: [email protected]
Introduction
likely to generate more expenses compared with those with
other pain conditions [8]. Although early and intense care of
neuropathic pain is important, diagnosing neuropathic pain is a
challenge because lesions of the somatosensory nervous
system are not readily detectable. Unlike non-neuropathic pain
conditions, neuropathic pain usually reveals characteristic
symptoms such as “burning sensation,” “prickling sensation,”
and/or a sensation of “electric shock [9].” On the basis of such
characteristic descriptions, screening tools have been
developed to identify the components of neuropathic pain from
a patient’s presentation of symptoms.
The painDETECT questionnaire (PDQ) is one of the
screening tools of neuropathic pain, which was published by
Freynhagen et al. from Germany [10,11]. They established the
usefulness and validity of this brief, self-administered
questionnaire in identifying neuropathic components of pain in
patients with chronic lower back pain. PDQ has already been
Neuropathic pain is defined as “pain caused by a lesion or
disease of the somatosensory system” [1], and its prevalence
reaches about 7%–8% in the European population [2,3]. A
variety of diseases such as diabetic polyneuropathy,
postherpetic neuralgia, spinal cord injury, and peripheral nerve
compression cause neuropathic pain, and they generally follow
a chronic course. Chronic pain in patients results in anxiety,
depression, and interference with sleep, normal work, and
social activities [4,5]. It has a strong negative impact on the
quality of life [6] and has been estimated to result in an
expense of more than $100 billion per year in direct medical
costs and about $100 billion as indirect costs from absenteeism
and decreased productivity at work in the United States [7].
Among chronic pain conditions, neuropathic pain impairs the
quality of life profoundly, and patients with neuropathic pain are
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The Japanese Version of the painDETECT
Figure 1. The painDETECT Questionnaire-Japanese version (PDQ-J).
doi: 10.1371/journal.pone.0068013.g001
synthesis of the translation. Third, two native English
translators, who were uninformed about the nature of the study,
completed back translations of the translated PDQ; thereafter,
back-translations were sent to the expert committee to detect
any existing cultural bias, and the final version of PDQ-J was
completed. Nevertheless, the validity of PDQ-J has not been
confirmed yet; therefore, this study aimed to assess the validity
and reliability of PDQ-J.
translated into Spanish [12], Dutch [13], and Japanese [14].
The Japanese version of PDQ (PDQ-J) was translated and
reported by one of the authors of the present study in 2007
(Figure 1). Translation and cross-cultural adaptation of PDQ-J
was performed in accordance as per the established guidelines
[15,16]. First, for forward translation, a professional native
Japanese translator and a bilingual Japanese physician
independently translated the original PDQ into Japanese.
Second, an expert committee, including specialists in pain
management, orthopedics, and methodology, conducted
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The Japanese Version of the painDETECT
Materials and Methods
of the body (2 points). A total score is calculated by adding the
scores from the three components; a high score indicates that
the pain is possibly neuropathic in nature.
The intensity of pain was assessed by a three-type NRS
where the patient is asked to grade the actual pain level
experienced, the maximum pain level experienced in the last
four weeks, and the average pain level experienced in last four
weeks on a scale of 0-10 (0 = no pain, 10 = worst pain
imaginable).
The SF-36 consists of eight subscales, namely physical
functioning, physical role functioning, bodily pain, general
health perceptions, vitality, social role functioning, emotional
role functioning, and mental health [18,19]. Each subscale is
transformed to a score ranging from 0 to 100, with lower scores
indicating poor health-related quality of life. For analysis, we
used two summed scores: the Physical Component Score
(PCS) and the Mental Component Score (MCS). Each score
has the same mean and standard deviation (50 and 10,
respectively) in a normal population.
The study protocol was approved by the institutional review
board of the Clinical Research Support Center of the University
of Tokyo Hospital. Participants provided their written informed
consent to participate in this study.
We conducted a multicenter observational study, and
patients from two adult populations were enrolled. All the
enrolled patients suffered from pain with an intensity of 3 or
more out of 10 on an 11-point numerical rating scale (NRS).
The first study group included patients with neuropathic pain
(NeP group) diagnosed by a pain specialist in the pain center
as per the guidelines established by the International
Association for the Study of Pain (IASP) [17]. In the pain
center, only neuropathic patients with stable disease condition
and tolerable pain were selected; in addition, they were
selected if it could be estimated that there would be little
change in their pain during the study period. The second study
group comprised patients suffering from acute nociceptive pain
(NocP group) induced by trauma or orthopedic patients with a
degenerative condition of the extremities. Moreover, patients
with cultural or language barriers or with poor mental health
status that prevented them from understanding or responding
to proposed questions were excluded from this study. Informed
consent was provided by selected patients from both the
groups. In the first survey, all patients were asked to complete
a set of questionnaires including PDQ-J, a three-type numeric
rating scale (NRS) of pain (i.e., pain during the survey, a fourweek average, and maximum pain experienced), and the
Medical Outcomes Study 36-Item Short-Form Health Survey
(SF-36). The patients answered questions regarding their
demographic data (e.g., age, sex, height, weight, occupation,
smoking history, and education). Thereafter, the physicians
reported the original diagnoses, comorbidities, and treatment
options. The second survey questionnaire was administered
only to the neuropathic patients 2–5 weeks after the first visit,
and it included the same set of three questionnaires with one
additional question regarding whether there was an increase,
decrease, or no change in pain since the administration of the
first survey.
PDQ comprises a main component along with two additional
components. In the main component, termed as “gradation of
pain,” the patient is asked to identify the presence of seven
pathological pain sensations: burning, tingling, or prickling
sensations, tactile and thermal allodynia, electric shock-like
sensations, numbness, and pressure-evoked pain sensation.
The patient grades the presence of each type of pain as
follows: 0 = never; 1 = hardly noticed; 2 = slightly; 3 =
moderately; 4 = strongly; 5 = very strongly. This main
component of PDQ yields scores from 0 to 35 points. A second
component of PDQ, termed as “pain course pattern,” is a
multiple-choice questionnaire accompanied by four pain charts;
the patient is asked to quantify the pattern of experienced pain
as follows: persistent pain with slight fluctuations (0 points);
persistent pain with pain attacks (−1 point); pain attacks without
pain between them (1 point); pain attacks with pain between
them (1 point). The third component of PDQ, termed “radiating
pain,” asks patients regarding radiation of pain to other regions
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Feasibility
We analyzed the number of unanswered questions to
evaluate the feasibility of PDQ-J.
Validity
To establish construct validity, we performed an exploratory
factor analysis with principal components extraction. The
Kaiser criterion (eigenvalues > 1.0) and Scree plot were used
to determine the number of factors. As for criterion-related
validity, we calculated the Pearson correlation coefficient
between PDQ-J, NRS, PCS (SF-36), and MCS (SF-36).
Following are the generally accepted rankings for coefficients:
1.0–0.81 (excellent); 0.80–0.61 (very good); 0.60–0.41 (good);
0.40–0.21 (fair); and 0.20–0 (poor) [20].
Reliability
Internal consistency was measured with Cronbach’s alpha.
Alpha coefficients of a magnitude of ≥0.70 were considered
useful as evidence of adequate scale reliability at the level of
group comparisons [21]. Repeatability was assessed by a test–
retest method. Retest was administered to neuropathic patients
more than two weeks after first survey. Intraclass correlation
coefficients (ICCs) between test and retest scores were
calculated from the data from patients who responded with no
change of symptoms between the two surveys; moreover,
those with coefficients >0.80 were considered as having
excellent reliability [22].
All statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS version 21.0) software.
Results
A total of 122 Japanese patients were recruited in this study.
However, nine patients were excluded because of incomplete
responses to the proposed questions; most (six of nine) of the
blank responses were to the question regarding the radiation of
pain. Following exclusions, a total of 113 patients were further
evaluated: 60 patients were diagnosed as having neuropathic
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The Japanese Version of the painDETECT
Table 1. Demographic data of study patients.
Table 4. Etiology of study patients.
NeP (n=60) (SD)
NocP (n=53) (SD)
P value (t-test)
Neuropathic Pain
Age (mean)
59 (15)
57 (18)
n.s.
Brachial Plexus Injury 12, Radiculopathy 12,
Male/Female
40/20
30/23
n.s.
Herpes zoster 11, Spinal cord injury 10,
Height (mean)
164 (10)
164 (11)
n.s.
Neuropathy 7, Phantom pain 5, complex
Weight (mean)
64 (17)
62 (13)
n.s.
regional pain syndrome 2, Carpal Tunnel
Duration (months)
63 (71)
2.3 (7.9)
<0.001
Syndrome 1, Thalamic pain 1
NeP: Neuropathic Pain, NocP: Nociceptive Pain
Nociceptive Pain
Fracture 32, Contusion/sprain 10,
Osteoarthritis 4, Muscle pain 3,
Dislocation 2, Tenosynovitis 1,
Rotator cuff injury 1
doi: 10.1371/journal.pone.0068013.t004
doi: 10.1371/journal.pone.0068013.t001
Table 5. PainDETECT Questionnaire-Japanese version
(PDQ-J): summary of patient responses (Q1-7).
Table 2. Demographic data of study patients (education).
Education
NeP (n)
NocP (n)
Middle school
8
11
High school
24
14
Junior college
6
13
University
16
15
Graduate university
4
0
Hardly
n (NeP/NocP)
Q1. Burning
Q2. Tingling
Very
No
noticed
Slightly
14
25
30
(4/10)
(11/14)
(9/21)
10
(0/10)
12 (6/6)
39
(13/26)
NeP: Neuropathic Pain, NocP: Nociceptive Pain
Q3. Pain by
17
30
24
doi: 10.1371/journal.pone.0068013.t002
touch
(8/9)
(15/15)
(10/14)
28
34
18
(9/19)
(16/18)
(11/7)
33
40
19
(8/25)
(23/17)
(12/7)
Q4. Electric
shock-like
Table 3. Demographic data of study patients (occupation).
pain
Q5. Pain on
cold/hot
Occupation
NeP (n)
NocP (n)
Employee
15
18
Q6.
15
23
19
Retired
19
12
Numbness
(1/14)
(5/18)
(7/12)
Self-employed
11
9
Q7. Pain by
28
22
Housewife
8
8
pressure
(18/10)
(8/14)
Part-time job
3
6
NeP: Neuropathic Pain, NocP: Nociceptive Pain
Student
1
0
doi: 10.1371/journal.pone.0068013.t005
Employer
1
0
stimulation
NeP: Neuropathic Pain, NocP: Nociceptive Pain
21 (17/4)
25 (17/8)
21 (12/9)
18
(14/4)
19
(18/1)
15
(12/3)
5 (5/0)
8 (6/2)
6 (6/2)
18 (12/6)
9 (8/1)
6 (4/2)
15 (12/3)
2 (2/0)
4 (3/1)
19 (13/6)
26 (14/12)
18
(17/1)
19
(10/9)
19 (17/2)
13 (7/6)
pain intensity scale, patients from the NeP group experienced
pain that was significantly more severe compared with that in
the NocP group. The PDQ-J and SF-36 scores revealed similar
trends: patients in the NeP group revealed lower physical and
mental functioning compared with that in patients in the NocP
group.
doi: 10.1371/journal.pone.0068013.t003
pain, and 53 were categorized as having nociceptive pain. The
demographic characteristics of these patients are presented in
Tables 1, 2, and 3; in addition, it lists specific etiologies of pain
in patients in the NeP group [brachial plexus injury (12
patients); radiculopathy (12 patients); herpes zoster (11
patients); spinal cord injury (10 patients); diabetic or alcoholic
polyneuropathies (7 patients); phantom pain (5 patients);
complex regional pain syndrome (CRPS; 2 patients); carpal
tunnel syndrome (1 patient); and thalamic pain (1 patient)] and
the NocP group [trauma in 47 patients (89%), and degenerative
diseases in 6 patients (11%)] (Table 4). Specific etiologies
included fractures (32 patients), contusion/sprains (10
patients), osteoarthritis (4 patients), muscle pain (3 patients),
dislocations (2 patients), tenosynovitis (1 patient), and rotator
cuff injury (1 patient).
Tables 5 and 6 presents the summary of patient responses
of PDQ-J, and Table 7 presents the scores for each
questionnaire in NeP and NocP group, respectively. On the
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5 (3/2)
Moderately Strongly strongly
Validity
The factor analysis by Promax rotation using the Kaiser
criterion (eigenvalues ≥1.0) and a Scree plot revealed that the
main component of PDQ-J consists of two determinative
factors, and it explained 62% of the variance. One of these
determinative factors can be termed as “spontaneous pain,”
and the other as “evoked pain.” For criterion-related validity,
the total score of PDQ-J revealed statistically significant
correlations with pain intensity, PCS (SF-36), and MCS (SF-36;
Table 8).
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The Japanese Version of the painDETECT
Table 6. PainDETECT Questionnaire-Japanese version
(PDQ-J): summary of patient responses (Q8-9).
Q8. Pain course pattern
n (NeP/NocP)
Persistent pain with slight fluctuations
46 (22/24)
Persistent pain with pain attacks
21 (12/9)
Pain attacks without pain between them
18 (3/15)
Pain attacks with between them
28 (23/5)
Q9. Radiating pain
n (NeP/NocP)
Yes
74 (35/39)
No
34 (23/11)
NeP: Neuropathic Pain, NocP: Nociceptive Pain
doi: 10.1371/journal.pone.0068013.t006
Table 7. Scores of Pain Intensity, Neuropathic pain, and
health-related outcomes.
Outcomes
NeP (SD)
NocP (SD)
P-value (t-test)
Pain Intensity-NRS (present)
6.5 (2.3)
4.3 (2.9)
< 0.001
Pain Intensity-NRS (average)
6.7 (2.0)
4.2 (2.3)
< 0.001
Pain Intensity-NRS (maximum)
8.3 (1.6)
6.6 (3.2)
< 0.001
painDETECT
18.6 (6.3)
11.8 (6.3)
< 0.001
PCS (SF-36)
26.6 (16.9)
34.3 (20.8)
< 0.05
MCS (SF-36)
41.6 (11.7)
52.7 (10.2)
< 0.001
NeP: Neuropathic Pain, NocP: Nociceptive Pain, NRS: Numerical Rating Scale,
Physical Component score, MCS: Mental Component Score
Figure 2. Relationship between results of first and
second PDQ-J scores in the retested patients.
doi: 10.1371/journal.pone.0068013.t007
doi: 10.1371/journal.pone.0068013.g002
SF-36: Medical Outcomes Study 36-Item Short-Form Health Survey, PCS:
7.2), respectively. Furthermore, ICC between the two scores
was 0.94 despite the relatively long interval between the two
surveys (Figure 2).
Table 8. Pearson correlation coefficient with PDQ-J.
PDQ-J
P Value
Pain-Intensity (NRS)
0.44
< 0.01
PCS (SF-36)
−0.27
< 0.01
MCS (SF-36)
−0.34
< 0.01
Discussion
This study demonstrated that PDQ-J has good validity and
reliability. In addition, the results obtained in this study were
comparable with those obtained in previous studies [11,12].
With regard to construct validity, the factor analysis revealed
that the seven Likert items of PDQ-J consist of two
determinative factors, which could be designated as
“spontaneous pain” and “evoked pain.” These factors are
consistent with clinical characteristics of neuropathic pain.
Further, with regard to criterion-related validity, the correlation
between PDQ-J and NRS, MCS (SF-36), and PCS (SF-36)
was moderate, indicating that PDQ-J can reflect pain intensity
as well as impairments of mental status and physical status of
individual patients. There is evidence from a previous study to
support this, in which patients with more intense pain revealed
higher total scores on PDQ [23]. Therefore, PDQ-J might be
used as a score of pain severity, although another study should
be conducted to validate this. In this study, we demonstrated
fair to good criterion-related validity, excellent internal
consistency, and high reliability with statistical significance,
although the number of patients was limited, particularly in the
NeP: Neuropathic Pain, NocP: Nociceptive Pain, NRS: Numerical Rating Scale,
SF-36: Medical Outcomes Study 36-Item Short-Form Health Survey, PCS:
Physical Component score, MCS: Mental Component Score
doi: 10.1371/journal.pone.0068013.t008
Reliability
The Cronbach alpha for the total score of PDQ-J was 0.78
and that of the main component of PDQ (i.e., “gradation of
pain”) was 0.80, which was comparable to 0.83 and 0.86
reported in the original and Spanish versions, respectively
[11,12]. The score for each of the nine questions in PDQ-J
revealed a statistically significant correlation with the total score
of PDQ-J. We could recruit 16 patients with neuropathic pain
for a test–retest study; of these, 11 patients reported no
change in their symptoms, and the data for each these patients
were evaluated. The average period between the two surveys
was 23.1 days [standard deviation (SD): 8.3]. The mean score
of the first and second survey was 20.4 (SD: 7.7) and 20.2 (SD:
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The Japanese Version of the painDETECT
have revealed that a neuropathic pain component is
underdiagnosed in a profound number of patients with pain,
thereby suggesting that patients with neuropathic pain are not
administered analgesics that are most effective in treating this
type of pain. Similar circumstances are probably present in
Japan as well. The results of the present study along with
confirmed reliability and validity of PDQ-J provide the rationale
to encourage extension of its use by general physicians in
Japan to promote appropriate pain management in patients
suffering with conditions involving chronic pain.
analysis of repeatability. As this study evaluated two distinct
types of pain, neuropathic and acute nociceptive pain in the
extremities, the methods and results obtained in this study
might be useful in a wide patient population suffering from
various types of pain.
Because the prevalence of patients with neuropathic pain is
limited in general population [24], neuropathic pain has not
been still recognized well in clinical settings all over the world
and also in Japan. However, the indications are that this type of
pain is more severe than non-neuropathic pain and results in
profound impairment of both physical and mental quality of life.
In addition, neuropathic pain is usually resistant to treatment
with
conventional
analgesic
medications
such
as
acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs), and yet, it is not uncommon that such ineffective
measures are prescribed for patients suffering from
neuropathic pain. On the other hand, it is well known that
specific medications such as tricyclic antidepressants and
pregabalin/gabapentine provide effective analgesia in patients
with neuropathic pain. Therefore, the detection of a neuropathic
pain component from a patient’s total pain presentation is
important in selecting the appropriate medication for
appropriate pain management; this is particularly true for
general physicians without expertise in pain management.
Screening tools for identifying neuropathic pain, such as PDQ,
Conclusion
This study confirms that PDQ-J has good reliability and
validity as a pain assessment tool. Thus, we encourage
researchers and clinicians to use PDQ-J for the assessment of
patients suffering from pain that is suspected to be neuropathic
in origin.
Author Contributions
Conceived and designed the experiments: KT MS. Performed
the experiments: YM KT MS YO SK JO TO NO ST JT.
Analyzed the data: KT YM. Wrote the manuscript: YM KT MS.
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